Q &A with Thomas H. Lee, MD
Targeting the chaos in health care delivery, he talks of getting health care systems to focus on outcomes instead of transactions

An internist and cardiologist, Thomas H. Lee, MD, is Network President for Partners Healthcare System and Chief Executive Officer for Partners Community HealthCare Inc., the integrated delivery system founded by Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. He is the Editor-in-Chief for The Harvard Heart Letter and Associate Editor of The New England Journal of Medicine, where he frequently contributes on the subject of quality improvement in health care. He was co-author with James J. Mongan of the 2009 book “Chaos and Organization in Health Care” .

He is a professor at Harvard Medical School and Harvard School of Public Health. His research interests include risk stratification and optimal management strategies for common cardiovascular problems, and improvement of quality of care. Dr. Lee also is a member of the Board of Directors of Geisinger Health System, and the Health Advisory Panel of the Congressional Budget Office. He recently spoke to a joint conference of the Division of General Internal Medicine at the University of Pennsylvania and the Wharton School’s Leonard Davis Institute (LDI) of Health Economics (LDI). Afterward, he talked with Zachary Meisel, MD, MPH, LDI Senior Fellow and Robert Wood Johnson Foundation Clinical Scholar and emergency physician at the University of Pennsylvania.

Q: Since health care reform passed, integrated delivery systems like yours have received a lot of attention. Could you share an insider’s experience of what it really means to build one of these systems?
A: In Massachusetts, it’s very obvious to all of us that covering everyone really is the right thing to do. No one in Massachusetts wants to unwind what we have.

What does that actually mean in terms of delivery of care? There are cost pressures, of course. We increasingly feel that our idealistic aspirations and pragmatic imperatives are one and the same. We have to make care more integrated, more coordinated, higher quality and more efficient, because we can’t just do regular fee-for-service medicine for more people with the same amount or even less money and make things work. The business imperative is the integration of care so that we can deliver outcomes rather than just transactions.

Q: You’ve written and spoken about value in health care. That’s one thing everyone agrees on. How do we frame that so it gets traction from the people who actually need it?
A: There are many different goals in medicine. People paying for health care are very focused on their costs going down. Advocates for minorities are focused on equity in care. Consumer advocates are focused on quality and access and satisfaction. Providers want to make their financial targets so they can protect their missions.

They’re all honorable goals, which are not shared by everyone else. That creates a situation where everyone is fighting for their goals—a gamesmanship world. That’s OK when the pie is expanding, but when the pie is not expanding and everyone is just trying to mitigate their damage, it gets pretty miserable. You can articulate value by measuring a range of different outcomes for a condition over the cost. We can all agree and come together around a constant push for improvement in that.

Q: Are we doing a good job selling that concept?
A: It’s an idea whose time has come. We’re seeing it manifest in CMS [Center for Medicare and Medicaid Services] payment policies that are emphasizing, for example, readmission and moving away from fee for service. I don’t think anyone just wants regular old capitation and shifting the risk to providers.

Q: What happens when a teaching and research organization, whose mission may include factors that are hard to quantify, is measured only on quality and value? Is that institution going to be penalized?
A: I actually believe we’re going to be fine, that we’re going to be there taking care of patients and we’re going to be respected by our marketplace. I also think that we attract a lot of young, creative people who will help us redesign our care and do more good things more effectively.

The flip side is that, like a lot of academic groups, we’ve got a lot of string quartets that don’t want to be in an orchestra—we’ve got a lot off dysfunction and confusion. But the most important thing that we are trying to do at Partners is to produce new knowledge that will help generations yet to come. In order to do that, we need to bring in the very best young people. But in order to do those two things, we have to be a very good delivery system. That’s the means to the end, because if we aren’t a very good and efficient delivery system, we’re going to be fighting off the wolves to protect our teaching and our research missions.

Q: Are we getting close to a backlash against some of these concepts such as accountable care organizations in health care reform, just like there was a backlash against managed care in the 1990s?
A: In Massachusetts when we talk about the need to go into new contract structures where providers are paid for outcomes or are paid on a term-per-month basis, to my shock, there is no pushback from the specialists that I deal with.

They see our schools laying off teachers and libraries closing, and they can see that health-care costs driving that. They see their kids are having trouble finding jobs, and they get it that something fundamental is going on here. If we don’t respond proactively and try to lead change, government and society should whack us if that’s what it takes to keep schools open, to keep libraries open and so on.

We are getting no push back, I mean zero, as we talk about need to become an accountable care organization.

Q: People in medicine are often navigating the system for people they know. Could we build those personal relationships into an integrated health care system and replicate that so that people who don’t have access could get the same benefit?
A: Absolutely. It’s important that we do it and that health systems get their act together. At the end of the day you need market share. If you can give people what they want, they will come to you—even if they pay a little bit more.

The kinds of functionality that we’re trying to create now include measuring cycle times— for example, the time between when someone is diagnosed with cancer and has a plan in place and the treatment begins. That is difficult for us to measure now because those data are generated in different parts or our health care system. However, it’s not unimaginable that we’ll be able to calculate those intervals. Once you can measure something, you can manage it.

Q: I love the concept of cycle time as a value. But I see people coming (or being sent) to the emergency department to get expedited care—which may not actually be needed right away. Is timeliness always a part of quality?
A: You focus on the important things. If a patient comes in with a TIA [transient ischemic attack] but he is not having an actual stroke, a lot of emergency department physicians in my institution will send that person home on aspirin and tell him to get an appointment with his primary care doctor or to see a neurologist.

Not all these patients need to be admitted, but they do need care soon. As you probably know, the 90-day stroke rate is around 9% with standard care, but if these patients get very prompt care in a day or two, the stroke rate is more like 2% or 3%.

They don’t need be filling a bed, but they do need to get an MRI, they need aggressive anti-platelet agent therapy. They need a different system than you have, than we have. That’s an important cycle time.

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